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THE CATARRHAL CHILD                              53

rhinitis, and they present the greatest problem in therapy. Silver protein
combined with ephedrine hydrochloride as nasal drops or spray (Argotone) is
most helpful in these cases.

Surgery is reserved for those children in whom clinical features warrant it.
Many children improve following the removal of adenoids when the discharge
from the nose is mucopurulent or when there have been attacks of otitis
media. Tonsillectomy is justified in those children who have recurrent attacks
of acute tonsillitis with clinical evidence of sepsis in the tonsils. Proof punctures
of the maxillary sinuses may be required if radiography suggests infection, and
in those cases in which pus is aspirated it should be cultured and the appropri-
ate antibiotic given, either by mouth or by direct injection into the sinus
through an indwelling polythene tube for 5-7 days.


The paranasal sinuses develop during childhood. At birth the maxillary,
ethmoidal and sphenoidal sinuses are present and the frontal sinuses begin to
grow shortly after birth as the nasofrontal ducts. The maxillary sinuses grow
into the body of the maxilla, occupying the space left as the primary and
secondary teeth move towards the alveolar margin. The floor of the antrum is
level with the floor of the nasal cavity about the age of 7 years, and thereafter
growth proceeds rapidly until the sinus attains its full size with the eruption of
the wisdom teeth. The ethmoidal and sphenoidal sinuses enlarge to form
recognizable sinuses between the ages of 4 and 6 years. The frontal sinus
develops more slowly, and is not recognized as a sinus until its cupola appears
above the level of the roof of the orbit radiographically, about the age of 8

Acute sinusitis may occur in children as a direct extension of an acute
rhinitis, but, as the openings of the sinuses into the nasal cavity are relatively
larger in children, they rarely close to set up the conditions for acute sinusitis.
Acute maxillary sinusitis is uncommon. Acute ethmoidal sinusitis may only
show itself when the infection has spread through the lamina papyracea to
cause an orbital cellulitis (Fig. 23). Acute frontal sinusitis may occur in the
older child and produce symptoms identical to those in the adult, except that
there is more often a visible swelling in the forehead over the affected sinus
due to an osteomyelitis of the frontal bone (see Fig. 37, p. 81). Treatment is
by antibiotics, giving a broad-spectrum antibiotic in full doses. Inhalations
should not be prescribed for a young child, in whom it may produce laryngeal
oedema, or for any child being treated at home because of the danger of the
inhalation fluid being spilled down the child's front. Local decongestant drops
or sprays of 0-5 per cent ephedrine hydrochloride in normal saline with silver
protein (Argotone) may be used.

Chronic sinusitis in children is usually confined to the maxillary sinus.
Chronic maxillary sinusitis may develop in children who suffer from repeated
head colds and in whom drainage of the infected rnucopus is hampered by
enlarged adenoids, by a deflected septum, or by enlargement of the conchae
from nasal allergy. The symptoms are persistent nasal catarrh of a muco-
purulent character, frequent, protracted head colds and nasal stuffiness.
The repeated upper respiratory tract infections may cause recurrent bronchitis,
bronchiectasis or pneumonia, and children with mucoviscidosis are generally